Building Bureau, Inc.
323 Washington St.
Woodland, Wa 98674
(360) 225-1217
Fax (360) 225-1489
Request for Mechanic's Lien Preparation

Member Name:
Member Number:
Member Phone:
Member E-mail:

Customer Name:
Customer Address:
Property Address:
Date of FIRST Delivery:
Date of LAST Delivery:
Date of Notice of Intent:

If property is in Oregon, please provide the following information:
Original amount of bid or contract broken down by:
  Labor: $
  Materials: $
  Equipment: $
  Total Bid: $
  Less Credit & Offsets: $
  Add Interest & Late Fees: $
  Change Orders or Add Ons: $
  Total Amount of Lien: $

Who from your company will be signing the lien, and his/her title:
If property is in Washington, please provide the following information:
Total Amount Due: $
I am the authorized agent for the company shown below and I understand that the preparation of the Mechanic's Lien is a service only. Building Bureau, Inc. assumes no responsibility or liability for the actual recording of the contents of the completed lien form or for the actual certified mail delivery made by the US Postal Service.
Full Name of Company, and Address
Initials Title Date